CHAPTER I

SMOKING

I. Definition
Smoking is the inhalation of the smoke of burning tobacco encased in cigarettes, pipes, and
cigars. Casual smoking is the act of smoking only occasionally, usually in a social situation or to relieve
stress. A smoking habit is a physical addiction to tobacco products. Many health experts now regard
habitual smoking as a psychological addiction, too, and one with serious health consequences.
II. Description
The U.S. Food and Drug Administration has asserted that cigarettes and smokeless
tobacco should be considered nicotine delivery devices. Nicotine, the active ingredient in
tobacco, is inhaled into the lungs, where most of it stays. The rest passes into the bloodstream,
reaching the brain in about 10 seconds and dispersing throughout the body in about 20 seconds.
Depending on the circumstances and the amount consumed, nicotine can act as either a
stimulant or tranquilizer. This can explain why some people report that smoking gives them
energy and stimulates their mental activity, while others note that smoking relieves anxiety and
relaxes them. The initial "kick" results in part from the drug's stimulation of the adrenal glands
and resulting release of epinephrine into the blood. Epinephrine causes several physiological
changesit temporarily narrows the arteries, raises the blood pressure, raises the levels of fat in
the blood, and increases the heart rate and flow of blood from the heart. Some researchers think
epinephrine contributes to smokers' increased risk of high blood pressure.
Nicotine, by itself, increases the risk of heart disease. However, when a person smokes,
he or she is ingesting a lot more than nicotine. Smoke from a cigarette, pipe, or cigar is made up
of many additional toxic chemicals, including tar and carbon monoxide. Tar is a sticky substance
that forms into deposits in the lungs, causing lung cancer and respiratory distress. Carbon
monoxide limits the amount of oxygen that the red blood cells can convey throughout your body.
Also, it may damage the inner walls of the arteries, which allows fat to build up in them.
Besides tar, nicotine, and carbon monoxide, tobacco smoke contains 4,000 different
chemicals. More than 200 of these chemicals are known be toxic. Nonsmokers who are exposed
to tobacco smoke also take in these toxic chemicals. They inhale the smoke exhaled by the
smoker as well as the more toxic sidestream smoke the smoke from the end of the burning
cigarette, cigar, or pipe.
Here's why sidestream smoke is more toxic than exhaled smoke: When a person smokes,
the smoke he or she inhales and then breathes out leaves harmful deposits inside the body. But
because lungs partially cleanse the smoke, exhaled smoke contains fewer poisonous chemicals.
That's why exposure to tobacco smoke is dangerous even for a nonsmoker.
III. Health Risks of Cigarette Smoking

By 2001, an estimated 450,000 Americans died annually from diseases related to
cigarette smoking. According to the American Cancer Society, 3,000 nonsmoking adults die
each year of lung cancer from the effects of secondhand smoke. Pregnant women who smoke are
more likely to give birth to low-weight babies, and smokers have increased rates of heart disease
and respiratory problems.
In addition to those health risks, smokers are at a higher risk for the development of many
types of cancer. In fact, 38% of all cancer deaths in men and 23% of all cancer deaths in women
are believed to be attributed to cigarette smoking. As cigarette smoking becomes more prevalent
in developing countries, the incidence of particular diseases, such as lung cancer, has also
increased.















CHAPTER II
Lung Cancer
I. Definition
Lung cancer is a disease of uncontrolled cell growth in tissues of the lung. This growth may lead
to metastasis, which is the invasion of adjacent tissue and infiltration beyond the lungs. The vast majority
of primary lung cancers are carcinomas of the lung, derived from epithelial cells. Lung cancer, the most
common cause of cancer-related death in men and the second most common in women (after breast
cancer), is responsible for 1.3 million deaths worldwide annually. The most common symptoms are
shortness of breath, coughing (including coughing up blood), and weight loss.
The main types of lung cancer are small cell lung carcinoma and non-small cell lung carcinoma.
This distinction is important, because the treatment varies; non-small cell lung carcinoma (NSCLC) is
sometimes treated with surgery, while small cell lung carcinoma (SCLC) usually responds better to
chemotherapy and radiation. The most common cause of lung cancer is long-term exposure to tobacco
smoke. The occurrence of lung cancer in nonsmokers, who account for as many as 15% of cases [6], is
often attributed to a combination of genetic factors, radon gas, asbestos and air pollution, including
secondhand smoke.
Lung cancer may be seen on chest radiograph and computed tomography (CT scan). The
diagnosis is confirmed with a biopsy. This is usually performed via bronchoscopy or CT-guided biopsy.
Treatment and prognosis depend upon the histological type of cancer, the stage (degree of spread), and
the patient's performance status. Possible treatments include surgery, chemotherapy, and radiotherapy.
With treatment, the five-year survival rate is 14%.
II. Classification
The vast majority of lung cancer are carcinomasmalignancies that arise from epithelial cells.
There are two main types of lung carcinoma, categorized by the size and appearance of the malignant
cells seen by a histopathologist under a microscope: non-small cell (80.4%) and small-cell (16.8%) lung
carcinoma.[16] This classification, based on histological criteria, has important implications for clinical
management and prognosis of the disease.
a. Non-small cell lung carcinoma (NSCLC)
The non-small cell lung carcinomas are grouped together because their prognosis and
management are similar. There are three main sub-types: squamous cell lung carcinoma, adenocarcinoma,
and large cell lung carcinoma.
Accounting for 31.2% of lung cancers,[16] squamous cell lung carcinoma usually starts near a
central bronchus. A hollow cavity and associated necrosis are commonly found at the center of the tumor.
Well-differentiated squamous cell lung cancers often grow more slowly than other cancer types.[4]
Adenocarcinoma accounts for 29.4% of lung cancers.[16] It usually originates in peripheral lung
tissue. Most cases of adenocarcinoma are associated with smoking; however, among people who have
never smoked ("never-smokers"), adenocarcinoma is the most common form of lung cancer.[20] A
subtype of adenocarcinoma, the bronchioloalveolar carcinoma, is more common in female never-smokers,
and may have different responses to treatment.
b. Small cell lung carcinoma (SCLC)
Small cell lung carcinoma (SCLC, also called "oat cell carcinoma") is less common. It tends to
arise in the larger airways (primary and secondary bronchi) and grows rapidly, becoming quite large.[22]
The "oat" cell contains dense neurosecretory granules (vesicles containing neuroendocrine hormones),
which give this an endocrine/paraneoplastic syndrome association.[23] While initially more sensitive to
chemotherapy, it ultimately carries a worse prognosis and is often metastatic at presentation. Small cell
lung cancers are divided into limited stage and extensive stage disease. This type of lung cancer is
strongly associated with smoking.[24]

c. Others
In infants and children, the most common primary lung cancers are pleuropulmonary blastoma
and carcinoid tumor.[25]
Secondary cancers
The lung is a common place for metastasis from tumors in other parts of the body. These
secondary cancers are identified by the site of origin; thus, a breast cancer metastasis to the lung is still
known as breast cancer. They often have a characteristic round appearance on chest radiograph. In
children, the majority of lung cancers are secondary.
Primary lung cancers themselves most commonly metastasize to the adrenal glands, liver, brain,
and bone.
d. Staging
Lung cancer staging is an assessment of the degree of spread of the cancer from its original
source. It is an important factor affecting the prognosis and potential treatment of lung cancer. Non-small
cell lung carcinoma is staged from IA ("one A"; best prognosis) to IV ("four"; worst prognosis). Small
cell lung carcinoma is classified as limited stage if it is confined to one half of the chest and within the
scope of a single radiotherapy field; otherwise, it is extensive stage.



III. Signs and symptoms

Symptoms that suggest lung cancer include:
* dyspnea (shortness of breath)
* hemoptysis (coughing up blood)
* chronic coughing or change in regular coughing pattern
* wheezing
* chest pain or pain in the abdomen
* cachexia (weight loss), fatigue, and loss of appetite
* dysphonia (hoarse voice)
* clubbing of the fingernails (uncommon)
* dysphagia (difficulty swallowing).

If the cancer grows in the airway, it may obstruct airflow, causing breathing difficulties. This can
lead to accumulation of secretions behind the blockage, predisposing the patient to pneumonia. Many
lung cancers have a rich blood supply. The surface of the cancer may be fragile, leading to bleeding from
the cancer into the airway. This blood may subsequently be coughed up.
Depending on the type of tumor, so-called paraneoplastic phenomena may initially attract
attention to the disease.[29] In lung cancer, these phenomena may include Lambert-Eaton myasthenic
syndrome (muscle weakness due to auto-antibodies), hypercalcemia, or syndrome of inappropriate
antidiuretic hormone (SIADH). Tumors in the top (apex) of the lung, known as Pancoast tumors,[30] may
invade the local part of the sympathetic nervous system, leading to changed sweating patterns and eye
muscle problems (a combination known as Horner's syndrome) as well as muscle weakness in the hands
due to invasion of the brachial plexus.
Many of the symptoms of lung cancer (bone pain, fever, and weight loss) are nonspecific; in the
elderly, these may be attributed to comorbid illness. In many patients, the cancer has already spread
beyond the original site by the time they have symptoms and seek medical attention. Common sites of
metastasis include the brain, bone, adrenal glands, contralateral (opposite) lung, liver, pericardium, and
kidneys.[31] About 10% of people with lung cancer do not have symptoms at diagnosis; these cancers are
incidentally found on routine chest radiograph.

IV. Pathogenesis
Similar to many other cancers, lung cancer is initiated by activation of oncogenes or inactivation
of tumor suppressor genes. Oncogenes are genes that are believed to make people more susceptible to
cancer. Proto-oncogenes are believed to turn into oncogenes when exposed to particular carcinogens.
Mutations in the K-ras proto-oncogene are responsible for 1030% of lung adenocarcinomas. The
epidermal growth factor receptor (EGFR) regulates cell proliferation, apoptosis, angiogenesis, and tumor
invasion. Mutations and amplification of EGFR are common in non-small cell lung cancer and provide
the basis for treatment with EGFR-inhibitors. Her2/neu is affected less frequently. Chromosomal damage
can lead to loss of heterozygosity. This can cause inactivation of tumor suppressor genes. Damage to
chromosomes 3p, 5q, 13q, and 17p are particularly common in small cell lung carcinoma. The p53 tumor
suppressor gene, located on chromosome 17p, is affected in 60-75% of cases. Other genes that are often
mutated or amplified are c-MET, NKX2-1, LKB1, PIK3CA, and BRAF.
Several genetic polymorphisms are associated with lung cancer. These include polymorphisms in
genes coding for interleukin-1, cytochrome P450, apoptosis promoters such as caspase-8, and DNA repair
molecules such as XRCC1. People with these polymorphisms are more likely to develop lung cancer after
exposure to carcinogens.
A recent study suggested that the MDM2 309G allele is a low-penetrant risk factor for developing
lung cancer in Asians.
V. Diagnosis
1. Chest radiograph showing a cancerous tumor in the left lung.

Performing a chest radiograph is the first step if a patient reports symptoms that may be
suggestive of lung cancer. This may reveal an obvious mass, widening of the mediastinum (suggestive of
spread to lymph nodes there), atelectasis (collapse), consolidation (pneumonia), or pleural effusion. If
there are no radiographic findings but the suspicion is high (such as a heavy smoker with blood-stained
sputum), bronchoscopy and/or a CT scan may provide the necessary information. Bronchoscopy or CT-
guided biopsy is often used to identify the tumor type.[3]

Abnormal findings in cells ("atypia") in sputum are associated with an increased risk of lung
cancer. Sputum cytologic examination combined with other screening examinations may have a role in
the early detection of lung cancer.

2. CT scan showing a cancerous tumor in the left lung.

The differential diagnosis for patients who present with abnormalities on chest radiograph
includes lung cancer as well as nonmalignant diseases. These include infectious causes such as
tuberculosis or pneumonia, or inflammatory conditions such as sarcoidosis. These diseases can result in
mediastinal lymphadenopathy or lung nodules, and sometimes mimic lung cancers. Lung cancer can also
be an incidental finding: a solitary pulmonary nodule (also called a coin lesion) on a chest radiograph or
CT scan taken for an unrelated reason.














VI. Treatment

Treatment for lung cancer depends on the cancer's specific cell type, how far it has spread, and
the patient's performance status. Common treatments include surgery, chemotherapy, and radiation
therapy.
1. Surgery




Gross appearance of the cut surface of a pneumonectomy specimen containing a lung cancer, here
a squamous cell carcinoma (the whitish tumor near the bronchi).
If investigations confirm lung cancer, CT scan and often positron emission tomography (PET) are
used to determine whether the disease is localized and amenable to surgery or whether it has spread to the
point where it cannot be cured surgically.
Blood tests and spirometry (lung function testing) are also necessary to assess whether the patient
is well enough to be operated on. If spirometry reveals poor respiratory reserve (often due to chronic
obstructive pulmonary disease), surgery may be contraindicated.
Surgery itself has an operative death rate of about 4.4%, depending on the patient's lung function
and other risk factors. Surgery is usually only an option in non-small cell lung carcinoma limited to one
lung, up to stage IIIA. This is assessed with medical imaging (computed tomography, positron emission
tomography). A sufficient preoperative respiratory reserve must be present to allow adequate lung
function after the tissue is removed.
Procedures include wedge resection (removal of part of a lobe), segmentectomy (removal of an
anatomic division of a particular lobe of the lung), lobectomy (one lobe), bilobectomy (two lobes), or
pneumonectomy (whole lung). In patients with adequate respiratory reserve, lobectomy is the preferred
option, as this minimizes the chance of local recurrence. If the patient does not have enough functional
lung for this, wedge resection may be performed. Radioactive iodine brachytherapy at the margins of
wedge excision may reduce recurrence to that of lobectomy.
Video-assisted thoracoscopic surgery and VATS lobectomy have allowed for minimally invasive
approaches to lung cancer surgery that may have the advantages of quicker recovery, shorter hospital stay
and diminished hospital costs.
2. Chemotherapy
Small cell lung carcinoma is treated primarily with chemotherapy and radiation, as surgery has no
demonstrable influence on survival. Primary chemotherapy is also given in metastatic non-small cell lung
carcinoma.
The combination regimen depends on the tumor type. Non-small cell lung carcinoma is often
treated with cisplatin or carboplatin, in combination with gemcitabine, paclitaxel, docetaxel, etoposide, or
vinorelbine. In small cell lung carcinoma, cisplatin and etoposide are most commonly used.Combinations
with carboplatin, gemcitabine, paclitaxel, vinorelbine, topotecan, and irinotecan are also used. in
extensive-stage small-cell lung cancer celecoxib may safely be combined with etoposide, this
combination showed improve outcomes.
3. Adjuvant chemotherapy for NSCLC
Adjuvant chemotherapy refers to the use of chemotherapy after surgery to improve the outcome.
During surgery, samples are taken from the lymph nodes. If these samples contain cancer, the patient has
stage II or III disease. In this situation, adjuvant chemotherapy may improve survival by up to 15%.
Standard practice is to offer platinum-based chemotherapy (including either cisplatin or carboplatin).
Adjuvant chemotherapy for patients with stage IB cancer is controversial, as clinical trials have
not clearly demonstrated a survival benefit. Trials of preoperative chemotherapy (neoadjuvant
chemotherapy) in resectable non-small cell lung carcinoma have been inconclusive.

4. Radiotherapy
Radiotherapy is often given together with chemotherapy, and may be used with curative intent in
patients with non-small cell lung carcinoma who are not eligible for surgery. This form of high intensity
radiotherapy is called radical radiotherapy. A refinement of this technique is continuous hyperfractionated
accelerated radiotherapy (CHART), in which a high dose of radiotherapy is given in a short time
period.[90] For small cell lung carcinoma cases that are potentially curable, chest radiation is often
recommended in addition to chemotherapy. The use of adjuvant thoracic radiotherapy following curative
intent surgery for non-small cell lung carcinoma is not well established and is controversial. Benefits, if
any, may only be limited to those in whom the tumor has spread to the mediastinal lymph nodes.
For both non-small cell lung carcinoma and small cell lung carcinoma patients, smaller doses of
radiation to the chest may be used for symptom control (palliative radiotherapy). Unlike other treatments,
it is possible to deliver palliative radiotherapy without confirming the histological diagnosis of lung
cancer.
Brachytherapy (localized radiotherapy) may be given directly inside the airway when cancer
affects a short section of bronchus. It is used when inoperable lung cancer causes blockage of a large
airway.
Patients with limited stage small cell lung carcinoma are usually given prophylactic cranial
irradiation (PCI). This is a type of radiotherapy to the brain, used to reduce the risk of metastasis. More
recently, PCI has also been shown to be beneficial in those with extensive small cell lung cancer. In
patients whose cancer has improved following a course of chemotherapy, PCI has been shown to reduce
the cumulative risk of brain metastases within one year from 40.4% to 14.6%.
Recent improvements in targeting and imaging have led to the development of extracranial
stereotactic radiation in the treatment of early-stage lung cancer. In this form of radiation therapy, very
high doses are delivered in a small number of sessions using stereotactic targeting techniques. Its use is
primarily in patients who are not surgical candidates due to medical comorbidities.
5. Interventional radiology
Radiofrequency ablation should currently be considered an investigational technique in the
treatment of bronchogenic carcinoma. It is done by inserting a small heat probe into the tumor to kill the
tumor cells.










VII. Targeted therapy
In recent years, various molecular targeted therapies have been developed for the treatment of
advanced lung cancer. Gefitinib (Iressa) is one such drug, which targets the tyrosine kinase domain of the
epidermal growth factor receptor (EGF-R), expressed in many cases of non-small cell lung carcinoma. It
was not shown to increase survival, although females, Asians, nonsmokers, and those with
bronchioloalveolar carcinoma appear to derive the most benefit from gefitinib.

Erlotinib (Tarceva), another tyrosine kinase inhibitor, has been shown to increase survival in lung
cancer patients and has recently been approved by the FDA for second-line treatment of advanced non-
small cell lung carcinoma. Similar to gefitinib, it also appeared to work best in females, Asians,
nonsmokers, and those with bronchioloalveolar carcinoma.
The angiogenesis inhibitor bevacizumab, (in combination with paclitaxel and carboplatin),
improves the survival of patients with advanced non-small cell lung carcinoma. However, this increases
the risk of lung bleeding, particularly in patients with squamous cell carcinoma.
Advances in cytotoxic drugs, pharmacogenetics and targeted drug design show promise. A
number of targeted agents are at the early stages of clinical research, such as cyclo-oxygenase-2
inhibitors, the apoptosis promoter exisulind, proteasome inhibitors, bexarotene, and vaccines. Future areas
of research include ras proto-oncogene inhibition, phosphoinositide 3-kinase inhibition, histone
deacetylase inhibition, and tumor suppressor gene replacement.
VIII. Prognosis
Prognostic factors in non-small cell lung cancer include presence or absence of pulmonary
symptoms, tumor size, cell type (histology), degree of spread (stage) and metastases to multiple lymph
nodes, and vascular invasion. For patients with inoperable disease, prognosis is adversely affected by
poor performance status and weight loss of more than 10%. Prognostic factors in small-cell lung cancer
include performance status, gender, stage of disease, and involvement of the central nervous system or
liver at the time of diagnosis.
For non-small cell lung carcinoma, prognosis is generally poor. Following complete surgical
resection of stage IA disease, five-year survival is 67%. With stage IB disease, five-year survival is 57%.
The five-year survival rate of patients with stage IV NSCLC is about 1%.
For small cell lung carcinoma, prognosis is also generally poor. The overall five-year survival for
patients with SCLC is about 5%. Patients with extensive-stage SCLC have an average five-year survival
rate of less than 1%. The median survival time for limited-stage disease is 20 months, with a five-year
survival rate of 20%.
According to data provided by the National Cancer Institute, the median age of incidence of lung
cancer is 70 years, and the median age of death by lung cancer is 71 years.

CHAPTER III
THE CORRELATION BETWEEN SMOKING AND LUNG CARCINOMA

Smoking, particularly of cigarettes, is by far the main contributor to lung cancer. Across the
developed world, almost 90% of lung cancer deaths are caused by smoking.In the United States, smoking
is estimated to account for 87% of lung cancer cases (90% in men and 85% in women). Among male
smokers, the lifetime risk of developing lung cancer is 17.2%; among female smokers, the risk is 11.6%.
This risk is significantly lower in nonsmokers: 1.3% in men and 1.4% in women. Cigarette smoke
contains over 60 known carcinogens, including radioisotopes from the radon decay sequence,
nitrosamine, and benzopyrene. Additionally, nicotine appears to depress the immune response to
malignant growths in exposed tissue.
The length of time a person smokes (as well as rate of smoking) increases the person's chance of
developing lung cancer. If a person stops smoking, this chance steadily decreases as damage to the lungs
is repaired and contaminant particles are gradually removed. In addition, there is evidence that lung
cancer in never-smokers has a better prognosis than in smokers, and that patients who smoke at the time
of diagnosis have shorter survival times than those who have quit.



Passive smokingthe inhalation of smoke from another's smokingis a cause of lung cancer in
nonsmokers. A passive smoker can be classified as someone living or working with a smoker as well.
Studies from the U.S., Europe,the UK, and Australia have consistently shown a significant increase in
relative risk among those exposed to passive smoke. Recent investigation of sidestream smoke suggests
that it is more dangerous than direct smoke inhalation.

CHAPTER IV
CONCLUSION

The most cost-effective means of fighting lung cancer. While in most countries industrial and
domestic carcinogens have been identified and banned, tobacco smoking is still widespread. Eliminating
tobacco smoking is a primary goal in the prevention of lung cancer, and smoking cessation is an
important preventative tool in this process. Most importantly, are prevention programs that target the
young. In 1998 the Master Settlement Agreement entitled 46 states in the USA to an annual payout from
the tobacco companies. Between the settlement money and tobacco taxes, each state's public health
department funds their prevention programs, although none of the states are living up to the Center for
Disease Control's recommended amount by spending 15 percent of tobacco taxes and settlement revenues
on these prevention efforts.
Policy interventions to decrease passive smoking in public areas such as restaurants and
workplaces have become more common in many Western countries, with California taking a lead in
banning smoking in public establishments in 1998. Ireland played a similar role in Europe in 2004,
followed by Italy and Norway in 2005, Scotland as well as several others in 2006, England in 2007,
France in 2008 and Turkey in 2009. New Zealand has banned smoking in public places as of 2004. The
state of Bhutan has had a complete smoking ban since 2005. In many countries, pressure groups are
campaigning for similar bans. In 2007, Chandigarh became the first city in India to become smoke-free.
India introduced a total ban on smoking at public places on Oct 2 2008.
Arguments cited against such bans are criminalisation of smoking, increased risk of smuggling,
and the risk that such a ban cannot be enforced.
The long-term use of supplemental multivitaminssuch as vitamin C, vitamin E, and folate
does not reduce the risk of lung cancer. Indeed long-term intake of high doses of vitamin E supplements
may even increase the risk of lung cancer.
The World Health Organization has called for governments to institute a total ban on tobacco
advertising in order to prevent young people from taking up smoking. They assess that such bans have
reduced tobacco consumption by 16% where already instituted.






REFERENCES

1. Available at: http://en.wikipedia.org/wiki/Lung_cancer Accessed August 10, 2009
2. Available at: http://www.answers.com/topic/smoking Acceessed August 11,2009
3. Available at: http://www.answers.com/topic/cigarette August 11,2009
4. Available at: http://quitsmoking.about.com/od/tobaccostatistics/a/CigaretteSmoke.htm Accessed
August 12,2009